Increasing isoniazid preventive therapy uptake in an HIV program in rural Papua New Guinea.

Setting: Tuberculosis (TB) is the leading cause of death among people living with the human immunodeficiency virus (PLHIV) in Papua New Guinea. Despite a policy for isoniazid preventive therapy (IPT) among PLHIV, implementation has been slow. Objective: We prospectively evaluated a standardized guided screening process, including TB diagnostic support, to increase IPT initiation in adult PLHIV on antiretro-viral treatment. Design: The guided process included a paper-based IPT screening tool that prompted review of patient history and TB symptoms and sputum analysis by smear microscopy and Xpert® MTB/RIF. Chest X-ray was performed at the provider's discretion. We quantified the yield of this guided process on IPT initiation and detection of TB and rifampicin resistance, and examined the contributions of each diagnostic modality. Results: Among 532 patients, TB was ruled out and IPT initiated in 450 (84%). TB was diagnosed and treatment was started in 82 (15%) patients. Xpert detected rifampicin resistance in one of 21 patients (5%, 95%CI 0.24-21.3) with a positive Xpert result. All TB cases were diagnosed by chest X-ray and/or Xpert. No cases were diagnosed by sputum smear alone. Conclusion: A standardized guided process, including TB diagnostic support, successfully enabled IPT initiation and identified a large burden of undetected TB.

Contexte : La tuberculose (TB) est la première cause de décès parmi les personnes vivant avec le VIH (PVVIH) en Papouasie Nouvelle Guinée. En dépit d'une politique en faveur du traitement préventif par isoniazide (TPI) parmi les PVVIH, la mise en oeuvre a été lente.Objectif : Nous avons prospectivement évalué un processus de dépistage standardisé guidé, incluant le soutien au diagnostic de la TB, pour augmenter la mise en route du TPI chez les adultes PVVIH sous traitement antirétroviral.Schéma : Le processus guidé a inclus un outil de dépistage sur support papier du TPI qui a suscité la revue des antécédents des patients, les symptômes de TB et l'analyse des crachats par microscopie de frottis et Xpert® MTB/RIF. Une radiographie pulmonaire a été réalisée à la discrétion du prestataire de soins. Nous avons quantifié le rendement de ce processus guidé relatif à la mise en route du TPI et à la détection de la TB et de la résistance à la rifampicine et examiné les contributions de chaque modalité de diagnostic.Résultats : Parmi 532 patients, la TB a été éliminée et le TPI a été initié chez 450 (84%) patients. Une TB a été diagnostiquée et le traitement a été mis en œuvre chez 82 (15%) patients. L'Xpert a détecté la résistance à la rifampicine chez un des 21 patients (5% ; IC95% 0,24­21,3) avec un résultat d'Xpert positif. Tous les cas de TB ont été diagnostiqués par radiographie pulmonaire et/ou Xpert. Aucun cas n'a été diagnostiqué par frottis de crachats seul.Conclusion : Un processus guidé standardisé, incluant la soutien au diagnostic de la TB, a permis la mise en route du TPI et identifié une large charge de TB non détectée.

Marco de referencia: La tuberculosis (TB) es la principal causa de muerte en las personas infectadas por el virus de la inmunodeficiencia humana (VIH) en Papua Nueva Guinea. Pese a las políticas vigentes en materia de tratamiento preventivo con isoniazida (TPI) en las personas afectadas por el VIH, su aplicación ha sido lenta.Objetivo: Se evaluó de manera prospectiva un procedimiento normalizado dirigido de detección sistemática, que comprendía el apoyo al diagnóstico de la TB, con el objeto de aumentar la tasa de iniciación del TPI en los adultos aquejados de infección por el VIH que recibían tratamiento antirretrovírico.Método: El procedimiento dirigido comportaba un instrumento impreso de detección para el TPI, que incitaba la evaluación de los antecedentes del paciente, los síntomas de TB y un análisis del esputo mediante la baciloscopia y la prueba Xpert® MTB/RIF. La radiografía de tórax se practicó según el criterio del profesional de salud. Se cuantificó el efecto de este método dirigido sobre la iniciación del TPI, la detección de la TB y la resistencia a rifampicina y se examinaron además las contribuciones de cada modalidad diagnóstica.Resultados: De los 532 pacientes, en 450 se descartó el diagnóstico de TB y se inició el TPI (84%). Se diagnosticó la TB y se inició el tratamiento a 82 personas (15%). Mediante la prueba Xpert se detectó la resistencia a rifampicina en uno de los 21 pacientes con resultado positivo a esta prueba (5%; intervalo de confianza del 95% de 0,24 a 21,3). Todos los casos de TB se diagnosticaron mediante la radiografía de tórax, la prueba Xpert o ambas. La baciloscopia por sí sola no permitió el diagnostico de ningún caso.Conclusión: Un procedimiento normalizado dirigido, que comportaba apoyo al diagnóstico de la TB, hizo posible la iniciación del TPI y favoreció el reconocimiento de una gran carga de morbilidad por TB no detectada.

Predictors of HIV testing and serostatus amongst children admitted to Port Moresby General Hospital.

The aim of this study was to identify factors associated with current HIV (human immunodeficiency virus) testing practice at Port Moresby General Hospital and positive serostatus among children tested, as a basis for contributing to guidelines on HIV testing for children in Papua New Guinea. Data were extracted from hospital records to determine the demographic and presenting clinical characteristics of admitted children tested for HIV serostatus between 1 December 2005 and 30 November 2006. These data were compared with corresponding data from untested control children from the same wards. The same characteristics were compared between seropositive and seronegative cases. Odds ratios were derived for potential predictors of testing and its outcome. During the study period, HIV tests were reported on 215 children, of whom 57 were seropositive. Controls were 264 untested children. Tested children were more likely to be aged 18 months or less, to have been admitted for more than 7 days, and to have diarrhoea, be malnourished or have oral candidiasis. Among children tested, suspected tuberculosis as a presenting illness was significantly predictive of HIV-positive serostatus. This study indicates that certain clinical factors associated with HIV-positive status in children may not yet have been incorporated into testing practice, and underlines the importance of developing a systematic approach to testing children for HIV in Papua New Guinea.

The management of children with cancer in Papua New Guinea: a review of children with cancer at Port Moresby General Hospital.

In the period of three and a half years between January 1998 and June 2001, 64 children with cancer were seen at the Paediatric Unit of Port Moresby General Hospital (PMGH). 62 children presented for the first time, whilst 2 were under review, having started treatment in 1996. The male:female ratio was 1.8:1. The median age was 60 months with an interquartile range of 36-84 months. 50% of the children were from the Port Moresby area, 15% from Central Province and 35% were referred from other provinces. Lymphoma, with Burkitt's lymphoma predominating, was as common as leukaemia. 20 (31%) of the children presented either at an advanced stage of disease or with cancer associated with a poor prognosis with available treatment, and were not offered curative treatment. 2 children transferred overseas for treatment. Of 42 families offered treatment 38 accepted and continued. At review 5 years after the start of the study 19 of the 20 children not offered treatment were known to have died and the outcome for 1 was unknown. Of the 38 children who underwent treatment at PMGH 24 (63%) were known to have died, 2 (5%) were still under treatment, 7 (18%) were in remission and the outcome for 5 (13%) was unknown. Of the 24 known to have died, remission induction failed in 16, relapse followed remission in 3 and 5 died from infection. The mean (SD) survival of those who died was 3.9 (3.4) months. 24 (51%) of the 47 known deceased children died in hospital, including 7 (32%) of the 22 referred patients. Significant problems were encountered in patient treatment. Infections occurred in 74% of treated children and drug shortages were experienced in 26%. The substantial problems faced by the families included marital discord, major financial hardship and, for those referred from other provinces whose children died, major delays and difficulties in repatriation. It is suggested that in Papua New Guinea the most appropriate approach to treatment for most children with cancer is the model in which paediatricians at the child's nearest appropriately staffed hospital take responsibility. Appropriate drug regimens, readily available drugs, ongoing advice and data collection should be coordinated through a central source. Accurate data should facilitate rational decisions.

Leukaemia in children in Papua New Guinea: an unusual pattern.

We report data on 110 children aged <15 years diagnosed with leukaemia during two periods covering 13.25 years. The data sets were consistent. The reported incidence of leukaemia was low. Only 34 (31%) of the children were diagnosed with acute lymphoblastic leukaemia (ALL) compared with 54 (49%) children with acute myeloid leukaemia (AML). The overall mean (SD) age was 6.6 (3.5) years, 6.1 (3.5) for ALL and 6.9 (3.5) for AML. There was no evidence of an early childhood peak of ALL. The male : female ratio was 1.2 : 1 for all leukaemias, 1.3 for ALL and 1.25 for AML. Only eight (22%) of those diagnosed with ALL were classified as type L1. Our figures reflect a relative absence of the common (cALL) cell type in early childhood leukaemia and support the role of infection and its effect on the immune system in the aetiology of childhood leukaemia. Our data also revealed an unusually high proportion of chronic myeloid leukaemia (CML).